Including Married Adolescents in Adolescent Reproductive Health and HIV/AIDS Policy docx

Including Married Adolescents in
Adolescent Reproductive Health and HIV/AIDS Policy


Paper prepared for the WHO/UNFPA/Population Council
Technical Consultation on Married Adolescents,
WHO, Geneva, 9–12 December 2003




Judith Bruce Shelley Clark
Director of Gender, Family, and Development Assistant Professor
International Programs Division Harris Graduate School of Public Policy
Population Council University of Chicago

Acknowledgments: We are particularly grateful to Annie Dude, University of Chicago, who
provided valuable and extensive assistance compiling the tables. We also wish to acknowledge
the financial support of the World Health Organization, the Bill & Melinda Gates Foundation,
the U.K. Department for International Development, The Ford Foundation, and The John D. and
Catherine T. MacArthur Foundation, all of which have supported a broad investigation into the
conditions of married adolescents’ lives. In addition, we thank Population Council staff members
Amy Joyce, Rachel Goldberg, and Erica Chong for their help in preparing this manuscript.

Contents


Introduction 1

The Traditional Omission of Married Adolescents 2

Why Are Married Adolescents at Risk? 4
Early Marriage Brings Intensified, and Often Riskier, Sexual Exposure 4
Social Isolation, Lack of Opportunity, and Low Status 6

Identifying the Policy Gap with Respect to HIV and Married Adolescents 9
Marginalisation of Married Adolescents in Prevailing Adolescent Sexual
and Reproductive Health Programmes 9
Lack of Prioritising Adolescents Within Safe Motherhood and MCH Programmes 10
Common HIV/AIDS Protection Messages Are Often Inappropriate
for Married Adolescents 10

Exercises to Guide Country-Specific Assessments of HIV Risks
Associated with Early Marriage 11
Estimating Levels and Distribution of HIV/AIDS in the Current Population 12
Determining Prevalence of Early Marriage for the Entire Country
and for Specific Subpopulations 12
Determining the Magnitude of the HIV Risks Accompanying Early Marriage 13
Percent of unprotected sexual activity occurring within marriage compared
to that occurring outside of marriage by age group 13
Mean age difference between married/unmarried adolescent girls and their partners 13
Assessing the Availability of and Access to Programmes and Services
for Married Women, Particularly Younger or Newly Married Women 14

Country Profiles in Brief 15
Burkina Faso 15
Zambia 15
Dominican Republic 16
India 17

Policy Options 18
Political Leadership 19

Premarriage Options 19
Evaluating the legal basis for eliminating underage/child marriages 19

Developing community-based initiatives that redefine acceptable ages of marriage
and offer incentives to parents and girls to delay marriage to legal age 20
Raising public awareness that marriage is not necessarily a safe place 22
Emphasising the importance of safe, age-appropriate spouses 23
Weighing whether later marriage will plausibly expand the number
of unmarried, sexually active, and at-risk adolescents 24
The Marriage Transition 24
Drawing on the sacred associations of marriage to communicate about
protection against HIV 25
Offering voluntary counseling and testing at the time of marriage 25
Redefining the First Year of Marriage as a Health Zone 26
Fostering more intimate and trusting relationships between new spouses 26
Decreasing the imminent pressure for pregnancy 27
Destigmatising condoms and protection from STIs/HIV within marriage 28
First Births and Beyond 29
Refining maternal health and adolescent sexual and reproductive health services
to bring married adolescents into the circle 29
Creating awareness of HIV and enhancing safety within marriage through
services at first birth 29

Summary 30

Tables 31



1
INTRODUCTION

In the past decade policy attention has turned toward adolescent reproductive health, and social

development issues have begun to take centre stage in international development policy. During
that same decade, the shape of the HIV epidemic shifted, with women of all ages now
comprising half of those infected with HIV/AIDS. Much of that acceleration in the spread of
HIV among women has taken place among adolescents. In some parts of the world, most notably
sub-Saharan Africa, HIV prevalence rates among young women aged 15–24 outpace those of
men in that age group by two to eight times.
1
Of substantial consequence, yet largely ignored, is
the fact that the majority of sexually active girls aged 15–19 in developing countries are married
(see Table 1, Columns 2 and 3)
2
and these married adolescent girls tend to have higher rates of
HIV infection than their sexually active, unmarried peers.
3
Thus married adolescent girls not
only represent a sizeable fraction of adolescents at risk, but they also experience some of the
highest rates of HIV prevalence of any group.
Nonetheless, married adolescents have been marginal in adolescent HIV/AIDS policies and
programmes and have not been the central subjects for programmes aimed at adult married
women.
4
We suggest that it is time—indeed past time—to give substantially greater attention to
the process of marriage and, specifically, the role that early marriage plays in potentially
exposing girls and young women to severe reproductive health risks, including HIV. Our
arguments and analyses suggest that married adolescents represent an acutely underserved group,
who in the context of an HIV epidemic are especially vulnerable. Epidemiological analyses have
failed to appreciate the importance of HIV prevention to young married women who are unlikely
to spread the disease through peer interactions. Yet, protecting these young women not only
serves to help prevent the disease from spreading from “high-risk” groups like sex workers and
truck drivers to the general population in their own generation, but also to the next generation by

reducing mother-to-child-transmission among this most intensive childbearing group.
5

In the next section, we offer a partial explanation for why married adolescents have so often
been overlooked. We then articulate the reasons why marriage, and particularly early marriage,
might bring elevated risk of HIV. After demonstrating a gap in HIV/AIDS policies for married
adolescents, we turn our attention to the implications and provide initial analytic tools to assist
policymakers in determining how to accord appropriate levels of priority to the marriage process

1
Laga, M., B. Schärtlander, E. Pisani, P.S. Sow, and M. Caraël. 2001. “To stem HIV in Africa, prevent transmission
to young women,” AIDS 15(7): 931–934; and UNAIDS. 2000. Report on the Global HIV/AIDS Epidemic.
Washington, DC: UNAIDS.
2
This statement excludes China, where marriage is typically later and data are missing.
3
Clark, Shelley. 2004. “Early marriage and HIV risks in sub-Saharan Africa,” Studies in Family Planning, 35(3):
149–160; Glynn, J.R., M. Caraël, B. Auvert, M. Kahindo, J. Chege, R. Musonda, F. Kaona, and A. Buvé for the
Study Group on Heterogeneity of HIV Epidemics in African Cities. 2001. “Why do young women have a much
higher prevalence of HIV than young men? A study in Kisumu, Kenya and Ndola, Zambia,” AIDS 15(suppl 4): S51–
S60; and Kelly, R.J., R.H. Gray, N.K. Sewankambo, D. Serwadda, F. Wabwire-Mangen, T. Lutalo, and M.J.
Wawer. 2003. “Age differences in sexual partners and risk of HIV-1 infection in rural Uganda,” Journal of Acquired
Immune Deficiency Syndromes 32(4): 446–451.
4
Because early marriage is a largely female phenomenon, and little data exist on married boys, this paper focuses on
the situation of married girls.
5
Childbearing is expected soon after marriage. Indeed, while age at marriage has generally increased, the average
number of months between marriage and first birth has decreased in all regions. Source: Mensch, Barbara. 2003.
“Trends in the timing of first marriage,” paper presented at the WHO/UNFPA/Population Council Technical

Consultation on Married Adolescents, WHO, Geneva, 9–12 December.

2
and married adolescents in HIV/AIDS prevention efforts. Then, five brief case studies illustrate
how the indicators suggested in the previous section can be implemented in specific settings.
Lastly, we offer a menu of potential policy interventions and actions to make married
adolescents an integral part of reproductive health and HIV prevention initiatives.


THE TRADITIONAL OMISSION OF MARRIED ADOLESCENTS

Early marriage and the needs of married adolescents have been neglected in the past for
historical, legal, and socio-cultural reasons. It is essential to recognise that the adolescent
agenda—indeed the concept of “adolescence” itself—originated in Western cultures. Thus, the
adolescent policy agenda, in its brief history, has been framed by the priorities and cultural
experience of developed countries, where the proportions of married adolescents are relatively
low—though the United States ranks among the highest in Western countries at 1.3 percent for
boys and 3.9 percent for girls
.
6
Given their small numbers in these countries, married
adolescents’ needs and conditions have been, at best, a minor consideration. Rather, it has been
the experience of unmarried—often in-school—adolescents’ sexual initiation, risk-taking
behaviours, and, more recently, social environments that have been major themes of both
research and policy interventions. In some countries, such as Mexico, where significant priority
had been given to unmarried adolescents’ behaviours, recent research has begun to show that
“marital status and gender are key to understanding sexual behaviour.”
7

Legally, married adolescents have been sidelined. As international human rights efforts

gathered steam, many gender issues, including early marriage, received initially limited
attention. Though there have been pro-forma condemnations of early marriage in many
international policy documents, premature or involuntary marriages have not been major subjects
in the international human rights movement. The Convention on the Rights of the Child
(CRC)—the most natural basis for international attention—offers an extremely useful cross-
cultural definition of “childhood” (up to age 18) and a detailed vision of the needs and rights of
children and their evolving capacities; yet it allows countries to apply these rights and
protections only to the unmarried. The CRC permits signatory countries to determine whether
marriage removes girls (who form the vast majority of married children)
8
and boys from the
protected space of childhood: “A child means every human being below the age of 18 years
unless under the law applicable to the child, majority is attained earlier” (Article 1, CRC).
9


6
While the number of adolescents who are married by age 20 in the United States is relatively low, in some states
the number of marriages involving an adolescent is actually quite high. In the state of Utah, for instance, in 1995, 22
percent of marriages involved a bride under 20 years old; nationally the figure was 11 percent. In 1999 in the state of
Idaho, nearly 16 percent of all marriages involved a bride under 20 years old.
Source: United Nations. 2000. World
Marriage Patterns. New York: United Nations Population Division, Department of Economic and Social Affairs.
7
Vernon, Ricardo. 2003. “Adolescent reproductive health and sex education in Mexico,” paper presented at the
Youth Reproductive Health and HIV Prevention meeting, Washington, DC, 9 September. He noted that about 50
percent of ever sexually active girls were married.
8
In nearly all countries girls aged 15–19 are at least twice as likely to be married as boys; sometimes the probability
is much higher. For example, in Brazil the probability of marriage for girls is five times higher, while in Indonesia it

is seven and a half times higher. In Kenya girls are an astounding 21 times more likely to be married than boys of
the same age. Source: United Nations. 2000. See note 6.
9
For a discussion of the interpretation of early married with respect to the CRC, see the paper by Gabriella de Vita
of UNICEF presented at the WHO/UNFPA/Population Council Technical Consultation on Married Adolescents,
WHO, Geneva, 9–12 December 2003.

3
Indeed, some countries might not have signed the CRC without potential exemption to child
rights protection for married girls and women. This legal construction reflects and is justified by
a long-standing cultural norm—that marriage, regardless of age, confers adult status. Marriage
often marks the passage out of childhood and bestows social seniority and a different set of
rights—which may be more or less than those allotted to children.
A third closely related reason for the invisibility of the needs of married adolescents is
psychological in nature. The comforting thought that a married girl is “taken care of” and has
passed from the “protection” of her natal kin to that of her husband is almost universal. This
perception of marriage as a “safe place” may be heightened for parents, and plausibly for girls
themselves, who are concerned about the risks to unmarried girls’ reputations and sexual
“purity” in the context of rapidly changing cultural norms and a growing HIV epidemic.
10
The
concept that marriage provides safety and protection is echoed at high policy levels and among
some religious authorities. A recent debate in Trinidad about raising the age of marriage met
with objections from a high Hindu official who characterised marriage as a “safety net” for girls.
A Muslim colleague, defending a law that allowed 12-year-olds to marry, saw marriage as a
means to “protect the child” from unwanted pregnancy.
11

These historical, legal, and cultural influences, while understandable, have led to a collective
denial of the continuing and widespread occurrence of not just “early” but child marriage. Of the

331 million girls currently aged 10–19 who live in the countries of the developing world
excluding China, 163 million will be married by their twentieth birthday, if present trends
continue

. Over the next ten years, more than 100 million girls in those countries will be married
before their eighteenth birthday.
12

Not only are these numerous married adolescents largely invisible to policymakers and
programme administrators, but the risks of HIV within marriage, especially marriages
characterised by unequal power relations, have been sidelined during the first part of the HIV
epidemic. The initial protective strategies were developed in the context of relatively empowered
adults having consensual sex who, with support, could communicate well and find the means to
avoid pregnancy and infection. The initial successful strategies to protect against HIV addressed
the needs of the first wave of infections. In the United States, the epidemic was first reported and
gained high visibility among relatively affluent, well-educated men who had sex with men,
where pregnancy was not only undesirable but unachievable. In sub-Saharan Africa, the first
wave of infections was found among “wealthy men who could afford to travel, have multiple sex
partners, and pay for sex.”
13

Increasingly, however, the epidemic in all regions is moving rapidly among the poor and
those powerless to negotiate the terms of sexuality and, as a result, is becoming increasingly
selective of young people, especially girls and young women. Strategies that have been effective

10
From a study in Kenya of married girls, a researcher reports “emblematic” attitudes regarding the perception of
protection: “I am happy because I have now settled with my husband. I don’t go out looking for other partners and I
am not at risk of getting STDs, like AIDS” (age 21, married at 18, Nyahururu district). Source: Erulkar, Annabel.
2002. “Married adolescents in Kenya: Exploring the links between marriage and HIV infection,” unpublished draft,

11 November; and Erulkar, Annabel and Charles Onoka. 2003. “Tabulations of data from Adolescent and
Reproductive Health Information and Services Survey,” unpublished, Central Province, Kenya.
11
Richards, Peter. 1999. “Calling a halt to child marriages,” Inter Press Services, 17 August.
12
Population Council analysis of DHS data, with special thanks to Carey Meyers and Brian Pence.
13
Kiragu, Karusa. 2001. “Youth and HIV/AIDS: Can we avoid catastrophe?” Population Reports series L, no. 12,
Fall. Baltimore: Johns Hopkins University Bloomberg School of Public Health, Population Information Program, p.
5.

4
to some degree for the previous groups of at-risk populations will not necessarily be appropriate
or feasible choices for disempowered young women under pressure to become pregnant (e.g.,
young married women).


WHY ARE MARRIED ADOLESCENTS AT RISK?

Girls married before the age of 18 will face significant risks of HIV for two primary reasons.
First, crossing the threshold into marriage greatly intensifies sexual exposure via unprotected
sex, which is often with an older partner who, by virtue of his age, has an elevated risk of being
HIV-positive. Second, marriage changes girls’ support systems both inside and outside their
households, often leaving them more isolated from external social and public support and in a
lower position within their new household.

Early Marriage Brings Intensified, and Often Riskier, Sexual Exposure

Even as sexual relations outside of marriage are becoming more common in all parts of the
world, marriage remains the most common route to regular, sexual relations and their attendant

health risks for girls in developing countries. Of equal or greater relevance to HIV/AIDS
prevention policies is the fact that sex within marriage—whether formal or common law—is
overwhelmingly unprotected with respect to HIV and sexually transmitted infections (STIs).
14

The dramatic rise in the frequency of unprotected sex when moving across the marital boundary
is driven by not only the implication of infidelity or distrust associated with certain forms of
contraception, such as condoms, but often also by a strong desire to become pregnant (see
below).
In Table 1, Column 2, we find that in most of the 26 countries with data on sexual activity
among married and unmarried adolescents the majority of sexually active girls aged 15–19 are
married. In an additional five countries (Bangladesh, Egypt, India, Indonesia, and Turkey), we
can plausibly assume that more than 80 percent of sexually active girls are married as questions
about the sexual activity of unmarried adolescents were deemed either too sensitive or too rare to
warrant inclusion in the survey. Of the 31 countries, in only two do married adolescents
constitute less than 30 percent of sexually active adolescent girls.
Key to understanding the spread of HIV is the frequency of exposure. By this measure,
married adolescent girls’ share of risk increases substantially—as they comprise an even larger
proportion of girls who had sex last week. Marriage appears across the board to increase the
frequency of sex with the proportion of married girls who had sex last week higher than the
proportion married among sexually active girls in every country (Table 1, Column 2 vs. Column
3). Part of this increase in frequency may be attributed to access to privacy and availability of a
partner, but part may also result from greater coerced or forced sex, as sex is plausibly less
voluntary within marriage since it may be more difficult to say “no” to a husband than to a
boyfriend (see Table 5, Column 9, for percentage of wives who say it is okay for husbands to
beat their wives if they refuse to have sex with them).

14
In developing countries, between 2 percent and 6 percent of married couples use condoms. Source: Gardner, R.,
R.D. Blackburn, and U.D. Upadhyay. 1999. “Closing the condom gap,” Population Reports series H, no. 9, April.

Baltimore: Johns Hopkins University Bloomberg School of Public Health, Population Information Program.

5
Even more disconcerting, in terms of HIV risk, is that not only do married girls have sex
more frequently, but these encounters are much less likely to be protected with condoms. On
average across these 31 countries, 80 percent of unprotected sexual encounters among adolescent
girls occurred within marriage. South Africa has by far the lowest percentage of unprotected sex
occurring within marriage (13 percent), while in Gabon and Ghana about half of unprotected sex
is among married adolescent girls (53 percent and 49 percent, respectively). In all other
countries, between 68 percent and 100 percent of unprotected sex last week happened in
marriage (Table 1, Column 4). Columns 5 and 6 of Table 1 report the proportion of married and
unmarried girls who had unprotected sex last week. We can use these percentages to calculate
the risk of a married girl having unprotected sex last week relative to the risk of an unmarried
girl. Table 5 shows that the relative risk of having unprotected sex last week for married girls
compared to unmarried girls ranges from 4.4 in South Africa to over 100 in Nicaragua to nearly
500 in Rwanda.
The desire to become pregnant substantially explains these dramatic differences in levels of
unprotected sexual exposure, since there are currently no available methods that protect against
HIV but do not prevent conception. Not surprisingly, Table 2 shows that nulliparous married
adolescents are significantly more likely to desire to become pregnant in the next two years than
nulliparous unmarried sexually active girls, with about half of nulliparous married girls seeking
pregnancy compared with less than 15 percent of nulliparous unmarried girls. Interestingly,
nulliparous married adolescents seeking pregnancy have a higher sexual frequency than married
adolescents desiring a second or higher order birth.
Yet desire to, or even pressure to, become pregnant does not account for all of the difference
in frequency of unprotected sex, as shown in Table 3. Married adolescents were significantly
more likely to have had unprotected sex last week, regardless of pregnancy intentions. Although
this difference is much greater among girls who do not wish to become pregnant, even among
girls who are actively seeking pregnancy in the next two years, married girls were on average
three times as likely to have had unprotected sex last week. These results suggest both that

frequency of sex increases in marriage and that condom use is much less common (and probably
less acceptable) as a means of preventing a birth within marriage than outside of marriage. Thus,
the added, if unintentional, benefit of condom use for contraceptive purposes—their protection
against HIV and other STIs—is lost for married adolescents under pressure to become pregnant.
Apart from having more frequent unprotected sex, married adolescent girls are also likely to
have older partners, who are more likely to be HIV-positive. The increase in the numbers of
young females infected with HIV has led some policymakers and researchers to conclude that
large age differences in sexual partners leave adolescent girls at particular risk of infection.
Much media attention and some adolescent reproductive health informational efforts have
identified relationships between young single girls and their older “sugar daddies” as risky.
15
In
reality, in parts of sub-Saharan Africa at least, husbands of adolescent girls tend to be older than
the partners of unmarried sexually active adolescent girls.
16
Large age differences between
husbands and young brides (women married before the age of 20) are common, ranging from 4.7
years in Guatemala to 14.1 years in Guinea. Indeed, the younger a bride is at the time of
marriage the greater her age difference with her spouse (Table 4, Columns 6 and 7). For example

15
Luke, Nancy and Kathleen M. Kurz. 2002. “Cross-generational and transactional sexual relations in sub-Saharan
Africa: Prevalence of behavior and implications for negotiating safer sexual practices.” AIDS Mark report.
Washington, DC: International Center for Research on Women and Population Services International.
16
Clark. 2004. See note 3.

6
in the West African countries, women who marry before age 20 are on average 10.9 years
younger than their husbands, while women who marry after age 20 are 8.7 years younger. In

Latin America, too, young brides marry relatively older men than older brides; the average age
difference for women marrying before age 20 is 5.9 years, while it is 3.4 years for those
marrying later.
A concern about large age gaps between sexual partners is increasingly present in national
AIDS policies. Yet these policies often fail to acknowledge the role of marriage in creating and
entrenching such large age differences. For example, the 2002 national AIDS report from
Ethiopia—issued every two years by the Federal Ministry of Health—notes the higher infection
rate for females aged 15–19 over males, attributing it to “earlier sexual activity among females
and the fact that they often have older partners” (p. 16).
17
The same report makes no mention
18
of
marriage or specifically early marriage, although Ethiopia has a notably low age of marriage,
especially in some regions.
19
In Amhara region, two of the four urban sentinel sites report the
highest HIV-positive rates among pregnant women in the entire country (19.9 percent and 23.4
percent compared to 13.3 percent as the national urban average) while 50 percent of the girls in
this region were married under age 15.
20

Not only are husbands, on average, older than boyfriends, they are also more likely to be
infected. Clark (2004) calculates that in Kisumu, Kenya, 30 percent of male partners of married
adolescent girls were infected with HIV, while only 11.5 percent of the partners of unmarried
girls were HIV-positive.
21
She finds that similarly, in Ndola, Zambia, 31.6 percent of married
girls’ partners compared to 16.8 percent of unmarried girls’ boyfriends were found to carry HIV.
In many countries, depending on the stage of the epidemic, men aged 25–35 are significantly

more likely to have HIV, as well as other STIs such as HSV-2, than are younger men aged 15–
24. Thus, though we may need to be wary of the traditional meaning of “sugar daddy,” the
largest concentration of “sugar daddies” in our midst—albeit largely unacknowledged—are the
husbands of married adolescent girls.

Social Isolation, Lack of Opportunity, and Low Status

Married adolescent girls’ increased unprotected sexual activity, pregnancy-seeking status, and
older partners are not the only features of their lives that put their health in jeopardy. Marriage,
in most cases, removes girls from significant opportunities, freedoms, and rights, many of which
are guaranteed under the CRC.
22


17
AIDS in Ethiopia, 4th ed. 2002. A report from the POLICY Project, Disease Prevention and Control Department
of the Ministry of Health, Ethiopia.
18
The authors spoke with a number of the contributors to the Ethiopia AIDS report and there is indication that
attention will be given to marriage, including early marriage, in the next review.
19
The median age at first marriage in Ethiopia is 15.8 years. This calculation is based on data from women over 30
years of age, since nearly all women are married by this age.
20
Data are for 20–24-year-olds. Source: Central Statistical Authority and ORC Macro. 2001. Ethiopia Demographic
and Health Survey 2000. Addis Ababa and Calverton, MD: Central Statistical Authority and ORC Macro.
21
Clark. 2004. See note 3.
22
The rights guaranteed under the CRC, which may be curtailed by early marriage, include:

 the right to education (Article 28);
 the right to be protected from all forms of physical or mental violence, injury, or abuse, including sexual
abuse (Article 19) and from all forms of sexual exploitation (Article 34);
 the right to rest and leisure, and to participate freely in cultural life (Article 31);
 the right to seek, receive and impart information and ideas (Article 13); and

7
Social isolation is a loss in its own right and is increasingly identified as a predisposing factor
for HIV risk as it undermines the benefits of “social cohesion.” Social contact and networks are
becoming widely recognised as vital to transmitting information and supporting behaviour
change. Some analysts have credited part of Uganda’s success in reducing HIV infections to its
superior “social capital” and “cohesion” (supported by leadership at the top). Stoneburner and
colleagues find support for the hypothesis that “[e]lements of social capital and cohesion served
as catalysts to convert AIDS knowledge to personal modification of sexual lifestyles in Uganda
[emphasis added].”
23
Ugandans are more likely to receive AIDS information through personal
friendship networks,” which may “more effectively personalize risk and result in greater
behavioral change.”
24

In most countries, however, married girls report marriage as lonely, cutting them off from
friends and family, restricting social and geographic mobility, and limiting access to information,
schooling, and community participation. Marriage is often accompanied by a dramatic increase
in their workload.
25

The Self-Employed Women’s Association in Ahmedabad, India—a highly successful
organisation of mass mobilisations of women—sponsors a livelihood programme for both
married and unmarried adolescent girls. Coordinators of the project, describing the great

difficulty of engaging married girls, report that married girls’ “autonomy and mobility is even
more limited than unmarried girls and adult married women” (p. 6).
26
A First-Time Parents
project, operated by the Population Council with partners in Gujarat and Calcutta, found a
marked reduction in reported friends when girls moved from their natal to their marital homes;
96 percent of married girls in Gujarat and 25 percent in West Bengal said that they had had
friends when they lived in their natal homes, while only 67 percent and 7 percent, respectively,
reported having friends in the current marital home.
27
Baseline studies in Bangladesh compared
the spatial and social mobility of girls (married and unmarried) and boys (married and
unmarried). Among unmarried girls, 88.8 percent reported that they “have many friends in the
area” in contrast to only 40.5 percent of married girls.
28

Intriguingly, married adolescent girls’ isolation may extend to their access to media. Initial
reports from Asia (Indonesia and Nepal) suggested that married adolescent girls are more likely
to be outside the reach of radio and television. In rural Nepal, a smaller percentage of married
females aged 14–22 reported ever having watched television compared to single females in the
same age group.
29
This gap may be crucial as media and schools are increasingly enlisted to

 the right to educational and vocational information and guidance (Article 28).
23
Stoneburner, Rand, Daniel Low-beer, Tony Barnett, and Alan Whiteside. 2000. “Enhancing HIV protection in
Africa: Investigating the role of social cohesion on knowledge diffusion and behavior change in Uganda,”
presentation at the XIII International AIDS Conference, Durban, South Africa, 9–14 July.
24

Stoneburner et al. 2000. See note 23.
25
Diop, Nafissatou and Jacqueline Cabral N’Dione. 2002. “Senegal: Diagnostic study on the life experience of
married adolescent girls.” New York: Population Council.
26
SEWA/Population Council. 2003. “Building livelihood skills and opportunities for adolescent girls in Ahmedabad
and Vadodara districts,” baseline survey results. Gujarat, India: SEWA/Population Council.
27
Santhya, K.G., F. Ram et al. 2003. “The gendered experience of married adolescent girls in India: Baseline
findings from the First-Time Parents project,” paper presented at the 2nd Asia Pacific Conference on Reproductive
and Sexual Health, Bangkok, 6–10 October.
28
Department of Women’s Affairs. 2002. “Baseline survey report on rural adolescents in Bangladesh: Social life.”
Dhaka: Ministry of Women’s and Children’s Affairs, Government of the People’s Republic of Bangladesh, October.
29
Thapa, Shyam and Vinod Mishra. 2001. “Mass media exposure among urban youth in Nepal,” Population &
Reproductive Health, NAYA Report Series no. 10. Kathmandu: Family Health International, May (revised July).

8
convey HIV prevention messages and support HIV programmes. Finally, a social mapping
exercise undertaken in Burkina Faso found markedly different patterns of use of public space
among married girls compared to single girls. Married girls effectively had access only to public
places that served as a function of their duties as a wife and mother, such as health centres,
churches/mosques, markets, and the water pumps.
30

Married girls are also highly unlikely to be in school, which is an important setting in which
much of adolescent and HIV policy is mounted (see Tables 5 and 6 for more information). The
imbalance of attention to the schooling needs of married adolescent girls is evident in policies
governing who can or is encouraged to return to school. In South Africa, as in a number of

countries, there has been explicit policy change to encourage girls with babies to return to
school, but no parallel efforts have been made to keep married girls in school (regardless of their
childbearing status). Consequently, an estimated 45 percent of unmarried girls with babies are in
school as compared to 27 percent of married girls.
31
Similarly, in several countries, including
Brazil, married girls without children (12.8 percent) are even less likely than unmarried girls
with children (29.8 percent) to be in school (see Table 6). Further evidence that early marriage
diminishes educational achievement can be seen in Columns 10 and 11 of Table 5; married
adolescent girls in all countries are less likely to be in school than their single counterparts.
The low status of young brides in their new households may also exacerbate their
vulnerability to HIV. Given the typically large age gap with their husbands, younger wives have
even less negotiating power over when to have children; their preferred type of contraception,
particularly condoms; and their ability to refuse sex. They may also have less ability to demand
fidelity or to leave husbands they suspect or know are unfaithful. These young wives may also
feel more keenly pressure to have a child as quickly as possible to secure their position among
their husbands’ kin. A study of married adolescent girls in Kenya highlighted the physical
control imposed on girls by husbands. Seven percent of girls reported that their husbands had hit
them in the past month. One young woman, age 23, married at age 17, in Nyeri district said, “I
didn’t like the way he controlled me, like I was a toy. And on top of that, the weekly beatings he
gave me. He had warned me against having a friend.”
32

Married adolescent girls’ relative isolation from information and services as well as their low
status within the household limit their knowledge about HIV/AIDS and impinge on their ability
to heed HIV messages. In most countries married adolescent girls are as likely or less likely to
have heard of HIV compared to single, sexually active girls, and they are even less likely to
know a way to avoid AIDS (Table 5, Columns 1–4). Moreover, while the overwhelming
majority of married adolescents report having only one partner or doing nothing in response to
concerns about HIV, single girls drew on a wider range of protection strategies, including having

only one partner, using condoms, stopping all sex, or not initiating sex. In India, there is some
evidence that married women have very little exposure to AIDS messages. According to the
1998–99 National Family Health Survey (NFHS-2), “only 40 percent of ever-married women in
India had ever heard of AIDS, much less knew how to prevent it” (p. 4).
33
Even fewer married
adolescents (29.7 percent) had heard of HIV (Table 5).

30
Saloucou, Lydia and Martha Brady. 2003. “Community mapping exercise of public spaces for adolescents: Tools
for program planning.” New York: Population Council.
31
Roberts, Benjamin. 1999. School of Development Studies, UND from South Africa Statistics 1996 Census, 10
percent sample; special tabulations prepared for the Population Council.
32
Erulkar. 2002. See note 10.
33
Brown, Tim. 2002. “The HIV/AIDS epidemic in Asia,” Asia-Pacific Population and Policy no. 60. Honolulu:
East-West Center, Population and Health Studies, January (published in April).

9
IDENTIFYING THE POLICY GAP WITH RESPECT TO HIV
AND MARRIED ADOLESCENTS

Not only are married adolescent girls often isolated within their new households and from
external public and private support, but their needs have not been prioritised or sometimes even
considered in current reproductive health initiatives. Moreover, many of the most common
HIV/AIDS policies and messages are not appropriate for them.

Marginalisation of Married Adolescents in Prevailing Adolescent Sexual

and Reproductive Health Programmes

Adolescent reproductive health programming reflects the bias of adolescent programming in
general, that is, directing most, or even exclusive, attention to the needs of unmarried
adolescents. Four main types of adolescent reproductive health programmes consume the vast
majority of adolescent reproductive health resources: family life education programmes that
include HIV/AIDS education, youth centres, peer education as a primary communication
strategy, and youth-friendly health services.
As mentioned above, married girls often have received no schooling or are early school
leavers and consequently may not receive the benefits of family life education. Girls in general,
and certainly married girls, are either not served or are less well-served in youth centres than
males, particularly older, often nonadolescent males. The configuration of these youth centres
often actually discourages female participation.
34
Peer education programmes, which have
become increasingly popular, often operate without clear theories of how change takes place
within different peer groups and even often fail to define “peer.”
35
Evaluations of their
effectiveness fairly systematically identify the main benefits as being to the promoters
themselves. One of the few studies to track closely the characteristics of promoters, in this case
in Ghana, noted there were no married peer educators (among 106) and only 6 percent of the
contacts (among 526) were with married individuals.
36
As the above data on married adolescent
girls indicate, they have distinctive patterns of social mobility and more limited social networks
than unmarried girls, placing them arguably outside the reach of conventional peer-to-peer
programmes.
Some youth-serving organisations are beginning to track more carefully which youths they
serve, looking to define unmet need among different age, gender, schooling, and marital status

groupings. Fifteen such NGOs in Ethiopia recently undertook a six-week experiment to track
their service contacts. These valuable and needed services were highly concentrated among older
adolescent male, in-school, unmarried “youth,” and appeared to give only minimal attention to

34
Erulkar, Annabel. 2003. “Examining the gender dimensions of popular adolescent programs: What they could
offer adolescent girls and boys,” in Adolescent and Youth Sexual and Reproductive Health: Charting Directions for
a Second Generation of Programming, background document for a workshop of UNFPA in collaboration with the
Population Council. New York: Population Council.
35
Erulkar. 2003. See note 34.
36
Wolf, R. Cameron, Katherine C. Bond, and Linda A. Tawfik. 2000. “Peer promotion programs and social
networks in Ghana: Methods for monitoring and evaluating AIDS prevention and reproductive health programs
among adolescents and young adults,” Journal of Health Communication 5(suppl): January.

10
the subset of young, married girls who are arguably one of the largest groups at risk of poor
reproductive health outcomes—maternal morbidity and mortality and STI, even HIV, infection.
37

Finally, and paradoxically, youth-friendly health services, meant to be a major means of
improving adolescent reproductive health, are largely contraceptive services with some STI and
HIV information, counseling, and testing included and, where available, treatment. Adolescent
reproductive health programmes to date still give scant attention to marriage preparation and
often explicitly exclude antenatal, delivery, and postpartum care as key services.
We queried 26 key informants from 17 international organisations with extensive
knowledge of HIV and adolescent reproductive health programmes in a multitude of countries
about these programmes. Encouragingly, youth-oriented and HIV/AIDS prevention campaigns
are burgeoning. They reflect a range of diverse and often highly creative programmes that

frequently have a far-reaching impact. Although very few of these programmes keep detailed
records of the groups they have reached or served, most acknowledged that they have had very
few married adolescents among their clientele. Indeed, while these activities geared toward
adolescents are too innumerable to describe, respondents could not identify programmes that
specifically target married adolescents or have developed specific messages for them.

Lack of Prioritising Adolescents Within Safe Motherhood and MCH Programmes

Apart from adolescent sexual and reproductive health services, there are other key avenues to
reaching married adolescents via safe motherhood initiatives or maternal and child health (MCH)
services. Adolescent girls, however, may be inadequately served by these antenatal and
postpartum programmes given the elevated (combined social and clinical) risks of first births to
the youngest mothers.
38
Moreover, many of the services offered, such as contraception and
sterilisation, are not sought by recently married young women. Even as the HIV epidemic moves
into younger age groups, MCH programmes rarely make a special effort to reach the youngest
first-time mothers. The cost of antiretrovirals to prevent mother-to-child transmission of HIV is
declining, and a growing proportion of married women in developing countries are tested for
HIV during antenatal visits or shortly before delivery. As with many maternal and child
initiatives, however, the emphasis tends to be on protecting the child rather than on protecting
both the child and mother. Such programmes often fail to fully recognise that keeping young,
recently married girls, who are about to enter their peak childbearing years, HIV-free may be one
of the best strategies not only for preventing the transmission of the disease to the next
generation, but also for ensuring that these children are not orphaned.

Common HIV/AIDS Protection Messages Are Often Inappropriate
for Married Adolescents

Also of plausibly limited value are the strategies targeted to unmarried sexually active adolescent

girls in developing countries. Indeed, the authors’ review of benchmark publications on
adolescents and HIV found they implicitly or explicitly prioritise strategies for sexually active

37
Mekbib, T.A., A. Erulkar, and F. Belete. 2004. “Who is being reached by youth programmes: Results of a
capacity-building exercise,” brief communication in Ethiopian Journal of Health and Development, in press. For
more information contact Annabel Erulkar at
38
Miller, Suellen and Felicia Lester. 2003. “Re-orienting information, social support and services for the youngest
mothers,” paper presented at the WHO/UNFPA/Population Council Technical Consultation on Married Adolescents,
WHO, Geneva, 9–12 December.

11
unmarried youth in presumptively voluntary relationships in which pregnancy was not sought.
Many publications and policies failed even to mention early marriage as a factor of interest, even
though the conditions of early/child marriage meet the definition of “high risk.” In the current
debate over PEPFAR (the U.S. President’s Emergency Plan for AIDS Relief), for example, Tom
Flavin, a spokesperson for the Global AIDS Coordinator Office at the State Department, defined
“high-risk” as “any situation in which a person was ‘required’ to have sexual intercourse with an
individual whose HIV/AIDS status was unknown to him or her.”
39
Sadly, evidence consistently
shows that nearly all young brides fit this definition of “high-risk.” Yet Flavin’s additional
assertion that “condom distribution for use in high-risk situations is very much part of the
prevention strategy,” suggests that he is not thinking primarily about protecting individuals in the
“high-risk” situation of early marriage.
Thus, whereas the elements of married adolescents’ social profile are given attention as
potential components of being “at risk”—low educational levels, lack of social capital, social
isolation, sex with older partners, required sex with an individual whose HIV status is unknown,
economic dependence—early marriage itself has not been treated as a cross-cutting condition nor

an area for policy work.
Currently recommended strategies for HIV/AIDS protection and risk reduction have been:
 to abstain from sexual activity;
 to reduce sexual frequency;
 to change sexual partners (to a safer partner);
 to use a condom (male or female); and
 to observe mutually monogamous relations with an uninfected partner.
Not one of these, save the last idealised situation (mutual monogamy with an uninfected
partner), offers a feasible choice for newly married girls/women under pressure to become
pregnant with more powerful and/or older husbands.
As early marriage has not been highlighted in the development of HIV/AIDS messages and
no special efforts have been made to reach the newly married female, in many settings these girls
are less likely to know a way to protect themselves from HIV (see Table 5). Indeed, some may
even believe that they are protected by their marital status.
40



EXERCISES TO GUIDE COUNTRY-SPECIFIC ASSESSMENTS OF HIV RISKS
ASSOCIATED WITH EARLY MARRIAGE

In the latter part of this paper, we offer broad programmatic and policy recommendations that
countries may adopt, depending on how they gauge the risk of HIV that may accompany early
marriage. Herewith we suggest some analytic exercises to help determine the level of urgency in
a given country and shape its response.
Four key analyses are suggested; note that preliminary tabulations are presented in Tables
1–5:

39
Friedlin, Jennifer. 2004. “Scorecard on Bush finds rhetoric gap,” WE News Correspondent, 8 March.

40
Doumbia, Seydou and Martha Brady. 2002. Data from quantitative survey: Projet Promotion de la Jeunesse et des
Sports du Mali: Éléments d’information sur la vie des adolescents de 13 à 16 ans dans la commune I du district de
Bamako, Population Council. Tableau no 939: Pourcentage des adolescentes qui pensent que le mariage peut
protéger contre le SIDA. New York: UNFPA, March; and Bracher, M., G. Santow, and S.C. Watkins. 2002.
“Moving and marrying: Estimating the prevalence of HIV infection among newly-weds in Malawi,” paper presented
at the Population Association of America annual meeting, Atlanta, 9–11 May.

12

estimating levels and distribution of HIV/AIDS in the current population;
 determining prevalence of early marriage for the entire country and for specific
subpopulations;
 determining the magnitude of the HIV risks accompanying early marriage; and
 assessing the availability of and access to programmes and services for married women,
particularly younger or newly married women.

Estimating Levels and Distribution of HIV/AIDS in the Current Population

Estimating the age- and sex-specific prevalence, and, when possible, incidence of HIV among
different populations is the first step in assessing what, if any, role early marriage or marriage per
se will play in either stemming the tide of HIV or serving as its bridge to the general population.
We do not delve into these statistics in this paper since most governments have been monitoring
HIV prevalence, at least among the “high-risk” groups such as sex workers, migrant workers,
and truck drivers. It is equally important, though often more difficult, to gather prevalence data
from groups considered to be at low risk, like young, married, monogamous women. Their
situation is indirectly and incompletely revealed by sentinel data drawn from antenatal clinics,
which serve both married and unmarried pregnant women. These data often serve the function of
estimating prevalence in the general population, but are flawed with respect to estimating
prevalence among poor or unmarried women who are less likely to receive MCH care. Ideally,

we would have survey and biomarker data from a random sample of young men and women who
are followed longitudinally from age 15 to 30. This information would be invaluable in
determining the potential spread of the disease across the marital boundary and gauging the
relative risks pre- and postmarriage.
The bridging role that married male behaviour plays in the epidemic is increasingly noted.
For example, the East-West Center recently observed in its studies of the HIV/AIDS epidemic in
Asia that:

There is an obvious link between HIV subepidemics in sex workers and their
clients, the wives and girlfriends of the clients, and their children. Studies have
shown, however, that transmission from husbands to wives occurs slowly. In
several states of India, the average lag between the start of an HIV epidemic in
sex workers and the rise of infection levels among pregnant women has been
about five years (p. 2).
41


This latter observation strikes a slightly positive note insofar as it suggests there may be time to
prevent the epidemic from spreading to the general population by offering protection strategies
to wives.

Determining Prevalence of Early Marriage for the Entire Country
and for Specific Subpopulations

The prevalence of early marriage varies tremendously by country or within a given country
among specific cultural or geographic settings. For example, while the nationwide median age at
marriage is an important indicator, many countries have very low ages at marriage in some

41
Brown. 2002. See note 33.

13
specific parts of the country. (See Table 7 for areas where high proportions of girls aged 15 are
already married, such as the Kayes region in Mali and the state of Bihar in India where rates
reach nearly 40 percent and Amhara, Ethiopia, where rates are 50 percent)
Getting estimates of the pervasiveness of early marriage can be achieved by various
measures, such as the median age at first marriage, the percentage married by age 15 or 18, or if
life table data are not available, simply the percentage of 15–19-year-olds who are married (see
Tables 1 and 4). Although defining when early marriage is common enough to warrant special
attention should be left to each country, the CRC and a variety of other covenants suggest that
marriage before the age of 18 is effectively “child marriage.”

Determining the Magnitude of the HIV Risks Accompanying Early Marriage

To determine the degree to which marriage marks an abrupt increase in HIV risk, two main
measures should be considered: the percent of unprotected sexual activity occurring within
marriage and the average age difference between young brides (i.e., those married under age 20)
and their spouses.

Percent of unprotected sexual activity occurring within marriage compared
to that occurring outside of marriage by age group

This measure is particularly salient for adolescent girls. Even if the overall percentage of girls
married before the age of 18 is low, this group may still constitute a high percentage of girls at
risk (i.e., girls having unprotected intercourse). Estimates of this ratio can be calculated as shown
in Table 1. If, for example, more than a quarter of unprotected sex occurs within marriage, then
the reproductive health needs of these married adolescents should be recognised and met along
with the different needs of unmarried sexually active adolescents. The dramatic change in sexual
behaviours that usually coincide with marriage, whether or not a girl is sexually active before
marriage, can apply at any age or in any age group. Thus, this calculation is most useful among

the age group that experiences the most transitions into marriage; in some countries this may not
be ages 15–19, but rather ages 20–25.

Mean age difference between married/unmarried adolescent girls and their partners

Three aspects of age matter with respect to HIV risks and marriage: the age of the bride, the age
of the groom, and the age difference between spouses. A girl’s exact age at marriage, of course,
needs to be considered as both her biological and emotional stage of development may affect her
vulnerability to HIV. In addition, as discussed above, examining the age differential between
partners may serve not only as a proxy for the relative power in the relationship, but also (after
controlling for the age of the wife) as an estimate of the probability of infection among husbands.
Average age differences of greater than three years or particularly large age gaps (i.e., more than
10 years) found among subpopulations would also indicate that husbands are more likely to be
infected. When available, data on the average age difference of unmarried partners (girlfriends
and their boyfriends) compared with the average age difference of wives and husbands in the
same age group would offer an estimate of the expected differences in HIV probabilities in
specific settings between husbands and boyfriends.


14
Assessing the Availability of and Access to Programmes and Services
for Married Women, Particularly Younger or Newly Married Women

Analyses should be undertaken by governments and NGOs to evaluate the reach of programmes
that currently target or could target married adolescent girls. Regardless of whether such
programmes prioritise HIV messages, any social, economic, or health programme that reaches
married adolescent girls can be seen as a vital vehicle to stem the epidemic. The review to be
undertaken should consider how organised efforts currently reach:
 about-to-be-married girls and their partners and parents;
 newly married girls and their partners;

 early married women and their partners; and
 first-time pregnant young women and their partners.
Relatively simple exercises may be undertaken to generate data on coverage. For example, a
consortium of youth-serving organisations in Ethiopia recently tracked all contacts of peer
educators over a six-week programme, and discovered very limited contact with married girls
(about 22 percent of contacts, even in Amhara district where 80 percent of girls are married by
age 18).
42

Even without data on programme coverage, programme protocols and identification of
research on which they are based (if any) should be reviewed to discern whether any distinction
has been made between strategies for reaching (1) unmarried sexually active girls, (2)
nulliparous or currently married pregnant girls, and (3) older, and presumably married, higher-
parity women. The lack of such differentiated planning may serve as a presumptive indicator of
insufficient contact with married adolescents. As discussed above, programmes that are
nominally open to both married and unmarried girls find that, without special efforts, they get
very little participation from married girls.
A crude measure of the current ability to reach these groups is to compare stated knowledge
about HIV and protection strategies of married adolescents to the responses of their unmarried,
sexually active counterparts of the same age. As suggested in Table 5, this information could
assess HIV knowledge, protection strategies, women’s autonomy within marriage, ability to use
condoms, desired delayed childbirth, and so forth. Again, we note that while these differences in
information access or the applicability of protection strategies may be especially acute for
married adolescent girls who are under pressure to have their first child and consolidate their
marriages, and are relatively disempowered, they may also exist at older ages. Of special
importance in HIV/AIDS policies and programmes are the messaging and communication
strategies that accompany them. Have the messages been especially tailored to the newly
married? Are there clear plans for how to reach this group, given their relative social isolation?
On the positive side, some countries may have exceptional systems of contact with the
engaged, marrying, and young married populations. If such procedures and service

infrastructures exist, these may afford convenient, culturally acceptable points of contact and
intervention.



42
Data are for 20–24-year-olds. Source: Central Statistical Authority and ORC Macro. 2001. See note 20.

15
COUNTRY PROFILES IN BRIEF

While it is beyond the scope of this paper to identify the specific needs for all countries based on
their marriage and HIV profiles, we present four illustrative and contrasting scenarios to suggest
how the factors presented in Tables 1–5 and the analyses proposed in the previous section may
be used to weight the importance of reaching young women with realistic HIV messages as they
approach and cross the marital boundary. That said, each country (and possibly at the sub-
national, regional level) must assess its own needs and tailor a response to suit the context. We
have refrained from offering policy advice in the context of case studies in this section and have
saved such propositions for the end.

Burkina Faso

Burkina Faso has low, but increasing, HIV rates in high-risk subpopulations. The prevalence rate
is substantially higher among young women aged 15–24 (with estimates ranging from 7.8
percent to 11.7 percent) than among young men (3.2–4.8 percent). The prevalence rate among
sex workers in major urban settings is approximately 60 percent, while women in urban antenatal
clinics have a rate of under 8 percent.
Marriage profoundly shapes the sexual behaviours of girls, given that approximately two-
thirds of women aged 20–24 were married by age 18. Indeed, the contrasts between married and
unmarried girls are strong in Burkina Faso, perhaps stronger than in many settings. Married girls

are much more likely to have had unprotected sex; indeed, married girls are 12 times more likely
to report having had unprotected sex in the last week than are unmarried girls (Table 1, Column
8 [i.e., Column 5 divided by Column 6]). Even compared to sexually active unmarried girls, the
relative risk of married girls having had unprotected sex last week is still 2.6 times higher, which
is attributable both to the increased frequency of sex and to the decreased use of condoms.
Pressure to become pregnant shortly after marriage is also evident: 61 percent of nulliparous
married girls desire pregnancy in the next two years, and the mean interval between marriage and
first birth in this age group is 19.0 months (Tables 2 and 4). Yet even among girls who do not
wish to become pregnant, almost a fifth of married girls reported having unprotected sex last
week compared to 1 percent of unmarried girls (Table 3, Columns 4 and 5). Most strikingly, the
mean age difference between spouses is nearly 12 years (Table 4, Column 6), suggesting that
husbands are likely to have considerably more sexual exposure than their wives prior to marriage
and are more likely to be infected. Given this profile, we could classify Burkina Faso as a
country where early marriage for girls may be a particularly vulnerable point of entry for HIV
into the general population.

Zambia

Early marriage has often not been perceived as a risk factor in southern Africa largely because
South Africa, the largest country in the southern region, has a relatively late age at first marriage
and sexual experience outside of marriage is common. Compared to the other 30 countries
presented in Table 1, South Africa is a clear outlier with only 7.3 percent of sexually active
adolescent girls being married. Yet, in other countries in southern Africa, such as Mozambique,
Zambia, and Zimbabwe, sex for adolescent girls frequently occurs within marriage (the
percentage sexually active who are married ranges from 44 percent to 69 percent). Thus, while
South Africa represents one of the only countries where our analyses indicate that early marriage

16
is not a common context for HIV infection, in the rest of southern Africa where HIV/AIDS
epidemics are well underway, early marriage may be an important contributing factor.

In Zambia, low estimates of HIV prevalence rates indicate that 10 percent of men aged 15–24
and 26 percent of women aged 15–24 are infected. For women, this estimate can reach as high as
40 percent. Early marriage is common in Zambia with 52 percent of girls marrying by age 18.
Perhaps more unique to Zambia is that less than half (44 percent) of sexually active adolescent
girls are married, suggesting relatively high rates of premarital sexual activity. Strikingly,
however, married adolescents represent a clear majority of those who reported having
unprotected sex in the last week (82 percent), due mainly to a greater frequency of sex within the
marital relationship rather than a decrease in condom use. Over 40 percent of women (Table 5,
Column 9) felt it was justifiable for a husband to beat his wife if she refused to have sex.
Interestingly, these pronounced differences in current behaviours and reported behavioural
changes persist despite the large proportion (28 percent) of currently unmarried girls seeking
pregnancy in the next two years. On average, husbands of girls married before age 20 are 6.7
years older than their wives.
While Zambia has promoted several large youth outreach and family life education
programmes, these programmes, by and large, do not reach the sizeable proportion of adolescent
girls who are married. Thus Zambia represents countries where the need to implement special
efforts to reach married adolescents with protection strategies is especially pressing and where
ignoring the risks to married women may undermine its existing HIV intervention programmes.

Dominican Republic

The Dominican Republic can also be characterised as having low but rising HIV rates especially
among specific groups. With 2.5 percent of the population living with the virus, the Dominican
Republic already has one of the highest HIV prevalence rates in the Latin America and
Caribbean region, though these estimates are currently low compared to parts of Africa.
More than 35 percent of women marry before the minimum legal age of marriage of 18. Yet,
unlike in many other settings, these early marriages appear to be largely motivated by the
adolescent’s desire rather than parental preferences. In the Dominican Republic, informal
consensual unions, called marriages “without papers,” are more common than legal, formal civil
or religious marriages.

43
Indeed, informal marriage is most common among adolescent girls,
comprising over 92 percent of their unions. Relative to formal marriages, these marriages
without papers tend to be more precarious as the high proportion of already separated or
divorced girls aged 15–19 attests. Moreover, these informal marriages do not confer the same
legal rights or benefits as legal marriages upon separation, divorce, or widowhood. The
implications of these informal marriages for adolescent girls with respect to HIV risks have yet
to be thoroughly explored. Yet, high dissolution rates and low economic standing may contribute
to a relatively high rate of serial monogamy reported by young women in the Dominican
Republic.
Indeed, for adolescent girls these consensual unions and marriages are by far the most
common route to sexual relations in the Dominican Republic. Although over a quarter of girls
aged 15–19 are sexually active, nearly 80 percent of these girls are married. Only 7 percent of
never-married girls nationwide report having ever had sexual intercourse. In addition, married

43
Castro Martin, Teresa. 2002. “Consensual unions in Latin America: Persistence of a dual nuptiality system,”
Journal of Comparative Family Studies 33(1): 35–55.

17
adolescent girls have much lower rates of condom use than their unmarried counterparts. For
example, among sexually active girls 15–19 years old, 30 percent of those never married report
condom use at last sex, compared with 3 percent of married girls. As a result fully 96 percent of
unprotected sexual encounters in the last week among adolescent girls occurred within marriage
(Table 1). Desire to become pregnant partially explains these differences in levels of unprotected
sexual exposure. Among nulliparous women, 30 percent of married girls compared to only 13
percent of unmarried girls desire a pregnancy in the next two years. The mean interval between
marriage and first birth is 20 months.
Among currently married 15–19-year-old girls, the mean age difference between partners is
7.2 years. By virtue of their age, older partners are likely to have had previous sexual partners;

indeed, the nationwide median age at first sex for males is 16.6 years, while their median age at
first marriage is 24.6 years, leaving a long interval for premarital relationships. In contrast the
median age at first sex for females is 18, while the median age at first marriage is about half a
year later at 18.6.
Married adolescent girls are more socially isolated than their unmarried peers. Although over
90 percent of unmarried girls aged 15–19 are currently in school in the Dominican Republic,
three out of five married girls are neither in school nor working (Table 5). Even when there are
no children to care for, marriage still limits school attendance. Unmarried girls aged 15–19
without children are nearly three times more likely than married girls without children to be in
school. Qualitative research has also revealed that married adolescent girls are less likely to
participate in community groups than either their unmarried counterparts or older married
women.
44
Thus, although the overall prevalence of HIV is low by international standards, the
high frequency of unprotected sex occurring within marriage and substantial difference in
spouses’ ages, coupled with the social isolation of married adolescent girls, makes them a
particularly important group to monitor and safeguard in the Dominican Republic.
45


India

India exemplifies the importance of evaluating the characteristics of each country (and
sometimes even regions within a country). Like the Dominican Republic the current prevalence
of HIV is relatively low, with less than 1 percent of the population infected (although rates are
already twice as high in women as in men). There is widespread concern, however, that the
disease is poised to spread from concentrated groups to the general population. Unmarried girls’
behaviours are closely monitored and premarital sexual experience for girls is strongly
discouraged. The age at marriage for girls is quite low and early marriage continues to be
common with over 60 percent of women married by age 18. Marriage, consequently, is the main

route to unprotected intercourse. However, compared to most other countries with similar marital
profiles, husbands are on average only a few years older than wives.
Measuring the relative magnitude and vulnerability of married adolescents in these settings is
often difficult, because the comparison group, unmarried sexually active adolescents, is often
missing from the data and/or comprise such small numbers as to render comparisons unreliable
(unmarried girls are not interviewed in the NFHS-1 or NFHS-2). Precisely because unmarried
girls are expected to refrain from sexual activity, however, we can infer that the transition to

44
Goldberg, Rachel. 2003. “Structures of risk: Gender and HIV/AIDS in the Dominican Republic,” master’s thesis,
Columbia University Mailman School of Public Health.
45
Goldberg. 2003. See note 44.

18
marriage and the coinciding HIV risks are especially stark. Indeed, it has been reported that at
most 10 percent of girls are sexually active before marriage, indicating that married girls
comprise well above 85 percent of sexually active girls and more than 95 percent of girls who
had unprotected sex last week.
46

Marriage also marks a transition to greater social isolation for many women in India. Upon
marriage girls often leave their natal homes and frequently move in with their husbands’ families
who may reside in another town or village.
47
Married adolescent girls in India also have very
little knowledge of HIV with only 30 percent having ever heard of HIV. Pressure to bear
children, especially sons, soon after marriage may be particularly acute.
The age gap between husbands and young brides in India (6.3 years) is smaller than in
Burkina Faso. Nonetheless, on average, this age difference is larger than the average spousal age

difference of older brides (women who marry after 20), which is 5.0 years. While conclusive
data are lacking, about 20–25 percent of unmarried school- and college-aged boys reported
engaging in premarital sex—often with a sex worker.
48
Since some, but certainly not all, young
men will come to marriage sexually experienced this additional 1.3-year age difference may
make an important difference in HIV rates among husbands of young brides.
The assumption that married women are at little if any risk of HIV has led to an alarming
discrepancy between married women’s real risk and their perception of risk. Two studies report
extremely limited knowledge or perception of risk for HIV among married, monogamous, HIV-
positive women in Mumbai.
49
While the first wave of HIV cases has already begun to hit high-
risk populations such as sex workers in Mumbai, there are warning signs that the second wave
will be among married women and that these women are ill-prepared to protect themselves and
their children. New studies are urgently needed to design appropriate policies. For example, in
cities or states where the HIV epidemic is underway, we need longitudinal studies that collect
information about sexual activity, knowledge regarding HIV, and, ideally, biomarkers of HIV
status for young women and men as they cross the marital boundary. A better understanding of
the risks of young men and women both inside and outside of marriage is vital to developing
appropriate policies.


POLICY OPTIONS

So far we have presented evidence suggesting that under certain circumstances marriage may not
represent a safety zone for girls and young women with respect to HIV. We have also identified
four key summary measures to give guidance for when marriage, especially early marriage,
might represent an important threshold for increasing HIV risks. In this next discussion, we
explore the policy options and decisionmaking points.

46
Santhya, K.G. and Shireen Jejeebhoy. 2003. “Sexual and reproductive health needs of married adolescent girls,”
Economic and Political Weekly 38(41): 11 October.
47
Elul, Batya. 2003. “Induced abortion in Rajasthan, India: Prevalence estimates from two quantitative
methodologies,” personal communication from a working paper.
48
Santhya and Jejeebhoy. 2003. See note 46.
49
Gangakhedkar, R.R., M.E. Bentley, A.D. Divekar, D. Gadkari, S.M. Mehendale, M.E. Shepherd, R.C. Bollinger,
and T.C. Quinn. 1997. “Spread of HIV infection in married monogamous women in India,” Journal of the American
Medical Association 278(23): 2090–2092; and Newmann, S., P. Sarin, N. Kumarasamy, E. Amalraj, M. Rogers, P.
Madhivanan, T. Flanigan, S. Cu-Uvin, S. McGarvey, K. Mayer, and S. Solomon. 2000. “Marriage, monogamy and
HIV: A profile of HIV-infected women in south India,” International Journal of STD & AIDS 11(4): 250–253.

19

Political Leadership

Before turning to a more systematic review of some of these, we highlight the important role
that leadership at the top must play in successful efforts to combat HIV transmission within
marriage. Thus a key policy decision that leaders need to make is whether delaying marriage to
at least age 18 and calling attention to the risks of HIV transmission within marriage will be
explicit elements in the HIV-prevention policy.
The most recent prime minister of Mozambique, Pascoal Mocumbi, was one of the first
national leaders to put forward a position on this question; he defined later and chosen marriage
as both a human right and an HIV-protection strategy and noted the “confusions” in parents’
minds regarding the safety that marriage offers to daughters. In an editorial in The New York
Times he cited the high HIV rates among young women and stated, “Parents know little about

sexuality, contraception, or sexually transmitted diseases, and many believe that early marriage
will ‘protect’ their daughters.”
50
Most recently, Nigeria joined the ranks of countries raising the
age of marriage to 18—with the explicit support of the highest-ranking Islamic cleric in Northern
Nigeria, the Saudana of Sokoto.
51
Although many different threads were interwoven in the
campaign for higher age of marriage, a concern about HIV played a role as a link was made
between girls’ school drop-out, early marriage, and HIV.
52
Another example, with more explicit
links and one that has received very little notice, was the statement by former President Daniel
Arap Moi of Kenya in 1999, raising the legal age of marriage from 14 to 18, citing the HIV
epidemic as a key factor.
53

Provided there is political will, specific policy measures for mitigating the risks of
contracting and spreading HIV via marriage can be identified and implemented. Below we have
provided an initial framework to guide country or subnational decisionmakers and advocates. For
the purpose of the exposition, we have organised these policy options in chronological order
from premarriage to post–first birth. The order does not, however, represent a ranking of
importance, and we are certain it does not cover the full range of options.

Premarriage Options

Evaluating the legal basis for eliminating underage/child marriages

In most countries, minimum ages of marriage were established as part of a charter of rights in a
society to define “adult” or majority status, and to offer protections to young men and women

and boys and girls (see Table 4, Column 1, for minimum legal age at marriage). In that spirit,
countries need to review the logic and justice of their laws, their cultural interpretation, levels of
compliance, and the implications for HIV risk if these laws are violated. A first task is the
alignment of national policies with the Convention on the Rights of the Child; the CRC
effectively establishes marriages before 18 as “under age” or “early marriage”—in effect, child
marriage. Most, but not all, countries are in compliance with this emerging international
standard. In some countries, this has meant equalising the ages for males and females since, in

50
Mocumbi, Pascoal. 2001. “A time for frankness on AIDS and Africa,” New York Times, 20 June, p. A23.
51
Generation 2000: Changing Girls’ Realities. Fonda Inc. and the International Women’s Health Coalition, 2000.
52
Dorothy Aken’ova, personal communication, 2003; Corinne Whitaker, personal communication, 2004.
53
Judith Achieng’. 1999. “Minimum consent age raised to curb spread of AIDS,” Inter Press Service, 29 November.

20
some countries, the age of legal marriage for males was considerably higher than that for
females.
In some settings, assuring the legal basis for deferring marriage to age 18 or beyond requires
confronting competing parental rights. In some settings, girls as young as age 12 can be married
with “parental consent.” The construction of such laws, of course, assumes the situation of young
people seeking marriage against their parents’ will. What is far more likely is parents’ exercising
absolute control over their children’s, principally their daughters’, lives by forcing early
marriage, nominally for economic or cultural reasons, such as protecting the family’s reputation.
At the recent Child Summit (2002), there was a debate over parental rights—often connected
to concern over adolescents’ independence and their reproductive rights. This debate has given
limited attention to arranged child marriages. There may be clear conflicts over whether parents’
arranging a marriage is their right or a violation of girls’ and boys’ rights. The Declaration of

Universal Human Rights and the CRC clearly give the young person the right to consent in
marriage and suggest, if the CRC age benchmark is accepted, that such consent cannot be given
until age 18.

Developing community-based initiatives that redefine acceptable ages of marriage
and offer incentives to parents and girls to delay marriage to legal age

While there is an understanding of the broad determinants of delayed marriage, and some
programmes appear to have made a contribution in that direction, experiments explicitly
designed to delay marriage are very few. Considerable attention has been given to the role that
education plays in delaying marriage; this role is not formal and direct as mandated schooling
often ends long before the time when marriages begin. However, it appears that girls with more
formal schooling continue to be married at a later age than girls with lesser or no schooling. The
school/delayed marriage link is part of a broader scheme of social and economic change that
makes it more likely girls will exercise choice in marriage as delayed marriage is more
economically sustainable.
54

The relationship between work and delayed marriage has received less attention, but there is
some evidence that girls who work for wages tend to marry later. Indeed in some communities,
the very prospect of working for wages (which requires some higher level of schooling) may
itself play a role in deferring marriage.
55
Some community-based social development initiatives
also appear to have spin-offs regarding age at marriage. Recently, the Centre for Development
and Population Activities (CEDPA) reported that its Better Life Options Program in India
appeared to contribute to a later age at marriage, although CEDPA calls for more research on the
exact mechanisms and the degree of change that can be attributed to the program.
56

One of the most purposeful community-based efforts to delay marriage that we could identify
was that of Maqattam—a project in the garbage-collecting districts of Cairo, Egypt. The
organisers of this several-decades-old programme discovered that underage marriages (under age

54
Mensch, Barbara S., Susheela Singh, and John Casterline. 2003. “Trends in the timing of first marriage among
men and women in the developing world,” draft, 12 June, submitted to Population Association of America 2004;
and Bruce, Judith, Barbara S. Mensch, and Margaret E. Greene. 1998. The Uncharted Passage: Girls’ Adolescence
in the Developing World. New York: Population Council.
55
Amin, Sajeda, Ian Diamond, Ruchira Tinaved, and Margaret Nubi. 1998. “Transition to adulthood of female
factory workers in Bangladesh,” Studies in Family Planning 29(2): 185–200.
56
Centre for Development and Population Activities (CEDPA). 2001. Adolescent Girls in India Choose a Better
Future: An Impact Assessment. Washington, DC: CEDPA.

21
16—the Egyptian law at the time) persisted even in the context of social, economic, and
environmental programmes that involve substantial numbers of girls in functional literacy,
income generation, and social development activities. Puzzled by the number of girls still
married at early ages, the sponsors of the Maqattam project established a Crisis Committee,
which often engaged in negotiating between family members in disputes. Such disputes included
girls’ appeals to the committee regarding pressure, sometimes outright coercion, to marry young
and to marry a suitor undesirable to them. There were cases of girls presenting themselves with
cuts on their wrists, and one told the story of trying to jump off her roof after being apprised of
her family’s plans. The Crisis Committee decided to change the terms of reference around early
marriage in the community by offering 500 Egyptian pounds (about US$150) to any girl who,
upon her marriage, could prove that she was past her eighteenth birthday and that the marriage
was voluntary. Working within a community setting where degrees of voluntarism and age
compliance could be discerned worked well. This programme has been in operation for the last

10 years. Since 1995, when the programme was established, a key organiser, Marie Assaad,
reports that no girls are known to have been married before age 18. Some 112 girls have been
explicit beneficiaries of the programme.
57

Given the dearth of examples of community-based efforts to promote later marriage, we may
look to the literature on efforts to reduce the extensiveness and degree of female genital cutting
(FGC). Though many countries in which FGC is widely practiced have prohibited it for decades,
these laws were unenforced and often unknown. Further, FGC—like early marriage—has often
been portrayed, even defended, as an integral part of local culture. The confluence of the
international human rights movement, economic and social changes, growing recognition of
women as citizens, and systematic documentation of the damage and death caused by FGC led to
the development of community-based efforts. These efforts typically combine accurate
information dissemination; social mobilisation of parents, elders, and other leaders in the
community; retraining of practitioners of genital cutting; and—in some instances—legal action
against purveyors of FGC or parents (such as recent cases in Tanzania and Ghana).
58

New initiatives to make marriage safer may build directly on existing FGC mobilisation
structures. For example, in Senegal, through the help of Tostan, an international,
nongovernmental organisation, over 800 communities have already made the declaration to end
FGC and, “in the coming months, hundreds of Bambara, Fulani and Diola Fogni communities
. . . will also pledge an end to FGC and early marriage to improve the health of girls and women
[emphasis added].”
59

While these examples are certainly at the edges of collective social action and innovation, if
and when early marriage is recognised as a human security crisis that undermines more
important community values and is linked to HIV, it is not impossible that communities will be
similarly motivated to take extraordinary measures to protect themselves. Though we will likely

57
Marie Assaad, personal communication; and Assaad, Marie and Judith Bruce. 1997. “Empowering the next
generation: Girls of the Maqattam garbage settlement,” SEEDS no. 19. New York: Population Council.
58
Mohamud, Asha, Samson Radeny, Nancy Yinger, Zipporah Kittony, and Karin Ringheim. 2002. “Protecting and
empowering girls: Confronting the roots of female genital cutting in Kenya,” in Nicole Haberland and Diana
Measham (eds.), Responding to Cairo: Case Studies of Changing Practice in Reproductive Health and Family
Planning. New York: Population Council, pp. 434–458; Ismailly, Jumbe. 2003. “Three get 30 years after FGM
victim dies,” , 11 October; and Ghana News Agency. 2003. “Woman gets five-year jail
term for performing FGM,” , 24 September.
59
Tostan News. 2003. “108 villages publicly declare the abandonment of FGC and early marriage in Salemata on
March 30, 2003,” , 30 March.

22
be unable to effectively or acceptably deal with early marriage unless there is community-level
mobilisation, at some point national governments will have to be ready to defend young women
against abuses of their rights and, in turn, hold accountable through legal measures those who
promote or force early marriage upon children.
60


Raising public awareness that marriage is not necessarily a safe place

Increasing the public’s willingness to raise the age of marriage—past the eighteenth birthday—
may require directly countering the common myth that early marriage will shelter adolescent
girls from risks, particularly sexual risks. Small, qualitative studies in Mali have found that a
surprising proportion of girls—almost 30 percent overall—either believe that marriage protects
them from HIV or “don’t know.”

61
In qualitative interviews in Malawi, parents often mention
their desire to marry their girls off early to protect them from the dangers of HIV.
62

The connections between early marriage and HIV risks must be made explicit and publicised
by political leaders and through the media. As with efforts to reduce FGC, messages about the
HIV risks associated with early marriage will need to move into the public sphere. A step in this
direction was a recently taken in the Dominican Republic where an educational film called
Daniela, which portrays the true story of a 17-year-old girl who was infected with HIV by her
husband, was widely distributed throughout the country. Other media efforts in different contexts
need to emphasise parents’ complicity in putting their children at risk by encouraging or even
forcing some marriages. A short film, produced as part of Scenarios of the Sahel, a media project
to make HIV/AIDS messages accessible, featured a story of a young girl who was married by her
greedy father to an older man.
63
While her father received a gold wristwatch, the results for the
girl were a better home and the acquisition of HIV. The final scene of the film shows the girl
returning to her home, heartbroken while explaining to her father that both she and her new baby
are HIV-positive. Throughout the film, the father is assailed by his conscience. The clear
message is that parents must not sell the health and rights of their children.
A recent study of the determinants of condom use among young people in urban Cameroon
can provide some guidance on how to make messages of HIV protection, including condom use,
salient to resistant and young populations. While this analysis was not directed at the behaviour
of young, married adolescents, it did consider the dilemma of young people in regular sexual
partnerships. The authors suggest that “youth-oriented programs seeking to increase the number
of new condom users among the young should promote parental support for condom use and
enhance young people’s perceptions of personal risk. Programs that work to convince the young
that their sexual history can put them at risk of HIV infection and that dispel the myth that HIV
risk with regular partners is low may serve to increase personal risk perception [emphasis

added]” (p. 335).
64
The authors also suggest that young people’s—most particularly girls’—
perceptions of their parents’ attitudes toward condom use may be an important determinant of

60
In Kenya, the African Inland Church Girls Primary School provides quality education and shelter to young girls
who have been “rescued” from early marriages. Source: “FAWE: Centering on excellence,” Carnegie Reporter 1(3):
Fall 2001,
61
Doumbia and Brady. 2002. See note 40.
62
Bracher, Santow, and Watkins. 2002. See note 40.
63
Nacro, Fanta Régina. 2001. “The voice of reason,” from the media project Scenarios of the Sahel. Ouagadougou:
Global Dialogues.
64
Meekers, Dominique, and Megan Klein. 2002. “Determinants of condom use among young people in urban
Cameroon,” Studies in Family Planning 33(4): 335–346.